Objectives:

• Awareness of common statistics and prevalence in geriatric population
• Know the muscles associated with continence
• Identify different types of incontinence
• Identify other implications of incontinence
• Identify commonly used outcome measures for incontinence
• Identify appropriate treatment option for incontinence
• Awareness of useful websites and links related to incontinence

Statistics and Facts:
- Subjects 65+, prevalence of incontinence is estimated to be 8-22% (Foley, et al., 2012)
- In elderly women estimated from 35-45% afflicted (Lekan-Rutledge, 2004)
- 10-35% of community-dwelling adults have incontinence (Goodman & Fuller, 2009)
- 50-60% of nursing home patients have incontinence (Goodman & Fuller, 2009)
- Only 20-50% of those afflicted with incontinence seek medical care (Goodman & Fuller, 2009)
- Consider to be a “Giant of Geriatric” (Foley, et al., 2012) Other Geriatric Giants – instability, immobility and confusion
- More common in Caucasian females (Foley, et al., 2012) (Goodman & Fuller, 2009)
- 8th most prevalent chronic medical condition among women in the US (Lekan-Rutledge, 2004)

Anatomy
- Pelvic floor muscles include (Hulme, 2000)

• Obturator internus
• Pelvic diaphragm (levator ani)
• Urogenital diaphragm
• External urinary and anal sphincters
• Hip adductors

- Other musculature involved with continence (Hulme, 2000)

• Breathing diaphragm
• Abdominals
• Latissimus dorsi
• Multifidus
• Gluteals

Types of Incontinence:

1. Urge
   1. Sudden, unexpected urge to urinate and the uncontrolled loss of urine (Goodman & Fuller, 2009)
   2. Other names: overactive bladder, hyper-reflexive bladder, detrusor hyperreflexia (Goodman & Fuller, 2009)
   3. Often related to reduced bladder capacity or detrusor inability (Goodman & Fuller, 2009)
   4. Associated with risk of falling (Foley, et al., 2012)
   5. Shown to be associated with poor physical health across the range of body systems (Foley, et al., 2012)
2. Stress
   1. Loss of urine during activities that increase intra-abdominal pressure such as coughing, lifting, or laughing (Goodman & Fuller, 2009)
   2. Associated with poor physical health across the range of body systems (Foley, et al., 2012)
   3. Associated with risk of falling (Foley, et al., 2012)
3. Functional
   1. Normal urine control but who have difficulty reaching a toilet in time because of muscle or joint dysfunction (Goodman & Fuller, 2009
4. Overflow
   1. Constant leaking of urine from a bladder that is full but unable to empty (Goodman & Fuller, 2009)
5. Mixed
   1. More than one of the above-mentioned types of incontinence
   2. Most common pair – urge and stress incontinence (Goodman & Fuller, 2009)
   3. Associated with risk of falling (Foley, et al., 2012)

Other Implications

• Impact of UI on health includes increased risk for skin rashes, dermatitis, secondary yeast infection, pressure ulcers, urinary tract infection, disrupted sleep patterns, falls, and fall-related injury (Lekan-Rutledge, 2004)
• People who experience both urinary incontinence and falls were significantly more likely to reports effects on their social life, symptoms of upset or distress and lower reported quality of life (Foley, et al., 2012)
• Link between those who experience urinary incontinence and falls with symptoms of anxiety and depression (Foley, et al., 2012)
• The larger the volume of urine lost, the greater the risk of falls (Foley, et al., 2012)

Common Outcome Measures

1. Pelvic Floor Manual Muscle Test (Grade 0-5) (Lekan-Rutledge, 2004) Scale for Strength of PME
0 - No palpable muscular contraction.
1 - Very weak contraction barely felt.
2 - Weak contraction that is clearly felt.
3 - Palpable contraction can’t be maintained against resistance.
4 - Contraction forceful but can’t resist opposition from
examiner’s finger.
5 - Maximum contraction strong resistance.

2. Incontinence Quality of Life Instrument (I-QOL)

1. http://www.physio-pedia.com/Incontinence_Quality_of_Life_Instrument

3. Male Urogenital Distress Inventory (MUDI)

1. http://www.physio-pedia.com/Male_Urogenital_Distress_Inventory_(MUDI)

4. Male Urinary Symptom Impact Questionnaire (MUSIQ)

1. http://www.physio-pedia.com/Male_Urinary_Symptom_Impact_Questionnaire_(MUSIQ)

5. Patient Global Impression of Improvement (PGI-I)

1. http://www.physio-pedia.com/Patient_Global_Impression_of_Improvement_(PGI-I)

6. Patient Global Impression of Severity (PGI-S)

1. http://www.physio-pedia.com/Patient_Global_Impression_of_Severity_(PGI-S)

7. Pelvic Floor Distress Inventory - 20 (PFDI - 20)

1. http://www.physio-pedia.com/Pelvic_Floor_Distress_Inventory_(PFDI_-_20)

8. Pelvic Floor Impact Questionnaire - 7 (PFIQ - 7)

1. http://www.physio-pedia.com/Pelvic_Floor_Impact_Questionnaire_(PFIQ_-_7)

Interventions
- Intervention preferences vary based on setting, patient, treating physician and involvement of the multi-disciplinary team. (Yates, 2017)
- According to one study on incontinence treatment in acute care setting, preferences were usage of diapers, medications, catheterization and scheduled toileting. (Pfisterer, Johnson II, Jenetzy, Hauer, & Oster, 2007)
- PATIENT EDUCATION! Must let patients know that it is NOT a normal process of aging. (Meadows, 2000)
- Behavioral treatments are best suited for those with stress, urge, or mixed urinary incontinence. (Meadows, 2000)
- Bladder/bowel diary to keep track of eating and drinking habits, frequency of voiding, etc. (Meadows, 2000)
- Voiding schedule and have patient work up to every 2 to 3 hours. (Meadows, 2000)
- Urge reduction which involves having the patient perform five quick pelvic floor exercises and concentrate on relaxing thoughts (not those associated with water such as ocean or waterfalls) to help decrease urge and overactive bladder. (Meadows, 2000)
- Neuromuscular re-education training using biofeedback and pelvic floor exercises to re-train pelvic muscles to increase continence. (Meadows, 2000)
- Gait and balance training to decrease fall risk. (Meadows, 2000)

Other Useful Websites/Links

1. Physiopedia Incontinence http://www.physio-pedia.com/Incontinence
2. American Urogynecologic Society (AUGS) at www.augs.org
3. American Urological Association (AUA) at www.auanet.org
4. International Continence Society (ICS) at www.icsoffice.org
5. National Association for Continence (NAFC) at www.nafc.org
6. National Institute on Aging at www.nia.nih.gov
7. Section on Women's Health, APTA at www.women'shealthapta.org
8. The Simon Foundation for Continence at www.simonfoundation.org

References

Foley, A., Loharlka, S., Barrett, J., Mathews, R., Williams, K., McGrother, C., & Roe, B. (2012). Association between the Geriatric Giants of urinary incontinence and falls in older people using data from the Leicestershire MRC Incontinence Study. Age and Ageing(41), 35-40.
Goodman, C., & Fuller, K. (2009). Pathology: Implications for the Physical Therapist . St. Louis : Saunders Elsevier .
Hulme, J. (2000). Research in Geriatric Urinary Incontinence: Pelvic Muscle Force Field. Topics in Geriatric Rehabilitation, 16(1), 10-21.
Lekan-Rutledge, D. (2004, August ). Urinary Incontinence Strategies for Frail Elderly Women. Urologic Nursing, 24(4), 281-302.
Meadows, E. (2000). Physical Therapy for Older Adults with Urinary Incontinence. Top Geriatric Rehabilitation, 16(1), 22-32.
Pfisterer, M., Johnson II, T., Jenetzy, E., Hauer, K., & Oster, P. (2007). Geriatric Patients' Preferences for Treatment of Urinary Incontinence: A study of Hospitalized, Cognitively Competent Adults Aged 80 and older. JAGS, 55(12), 2016-2022.
Yates, A. (2017). Urinary continence care for older people in the acute setting. British Journal of Nursing, 26(9), 528-530.